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In this reflective essay, I will address the importance of reflection and how it can influence the skills needed in nursing practice. I will also talk about the positive experience and knowledge gained from my clinical practice. In this essay, professional bodies and policies associated with nursing practice in a clinical setting will be highlighted. The aim is to address the learning outcomes of NHS constitution of Improving lives, which says ” we cherish excellence and professionalism wherever we find it -in the everyday things that make people live better as much as in clinical practice, service improvements, and innovation. We recognise that we all have a part to play in making ourselves, service users and others healthier.”
Reflecting on clinical practice is a key skill for nurses as the process of making sense of events, situations, and actions that occur in the workplace (Oelofsen, N. 2012). Looking back on what as happen enables we practitioners to manage the personal and professional impact of addressing our patient’s fundamental health and well-being needed daily (NCBI,2012)
The main aim of this reflective essay is to address and demonstrate the application core components of the Nursing and Midwifery Council (NMC) code of professional conduct by reflecting on my clinical practice. The (NMC code,2015) says make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay. Therefore, in this reflective essay, the importance of compassion and communication care in nursing practice will be alighted. National Health Service (NHS) values of practice are to understand that compassion can only be given through the level of relationship based on empathy, respect, and dignity. NHS constitution 2015-page 5 compassion, we ensure that compassion is central to the care we provide and kindness to each person’s pain distress, anxiety or need.
Compassion is fundamental to patient care and the need for compassion in practice is as strong as it has ever been. Care staff, Midwives, and Nurses are potentially in a position to advance the knowledge of patients, the quality of care outcomes across the range of health sector. (NHS England, 2013)
There are different numbers of reflective models that are used by professionals to evaluate past experiences. In this reflective essay, Gibb’s reflective model (1988) will be used, because this reflective model emphasises the role of emotions and acknowledges the significance of the reflective process. This reflective model gives me the ability to describe the factual description of what Ruth was going through, what did Daniel and I did to help Ruth with the pain. Also gives me the grace to express my feeling about Ruth situation.
The Gibbs reflective cycle is among the popular reflective models that have six steps: The first is a description which talks about the matter of fact of what happened during an incident, which I will be talking about management of dementia patient who was admitted to an acute rehabilitation ward. Feeling is the second step, which is the description or the analysis of my feeling as at the time of the incident. Next is the Evaluation, this is to evaluate what was good and bad about my experience with Ruth’s condition. The fourth is the analysis of the knowledge I can gain from Ruth’s situation. Next is the conclusion of what I could have done and what I should not have done. The last is the action plan, which is about what I will do if the situation arose again.
This essay will reflect on 96years old woman with increase confusion, chronic obstructive pulmonary disease (COPD) and was in pain. Dementia according to (care advantages, 2014) has a significant impact on communication, people lose their language skills and their ability to verbally communicate. This makes it difficult for Ruth to verbally communicate where she is having pain. Dementia is a clinical syndrome due to disease of the brain, usually of a progressive nature, which leads to disturbances of multiple higher cortical functions including memory, thinking orientation, comprehension, calculation, learning capacity, language, and judgment.
DESCRIPTIVE
Getting to my clinical placement on a certain Monday morning, I was with my mentor for the ward round and there is this patient whom I will name Ruth (Pseudonym) and my mentor’s name as Daniel (pseudonym) to maintain confidentiality. When we got to Ruth’s bedside she was lying in bed, Ruth was a scowling wrinkle of the eyebrow, tightly closing the eyes and unable to talk not because she can’t talk but she is weak. Her weakness was due to her not eating because of chronic obstructive pulmonary disease (COPD). Carpenito (2014) said COPD is a lung ailment that is characterized by a persistent blockage of airflow from the lungs. It is a life-threatening disease that interferes with normal breathing and is not fully reversible.
She was having difficulty in swallowing food and each time she struggled to eat she is always coughing. Daniel was sympathetic to Ruth condition and encouraged Ruth with the assurance that he will convey the message to the duty doctor regarding her state of health. Her state of health draws my attention on the area of the holistic approach of care that specifically talk about putting service user first in our clarity care (NMC, 2008) and this reminds me the importance of active listening. In this situation, I felt so bad about Ruth condition and can imagine the pain she was going through. COPD itself doesn’t cause pain directly but due to a continuous cough and the pressure on the chest wall, it can cause pain. COPD pain is mostly found in the shoulders, neck, lower back, and chest. The combination of pain, anxiety, difficulty sleeping and trouble breathing may take over the quality of life (Everyday health, 2017)
I seek permission from Daniel to have one to one with Ruth which I was granted. On getting to Ruth’s bedside I introduced myself telling her my name and that I am one of the student nurses, and told her I will be looking after her all day till 8pm when I will be handing her over to one of my colleague. I asked Ruth if she would like something to drink, Ruth was just looking at me. So I told Ruth that whatever question I will be asking her if it is yes, I want you to close your eye and if it is no, I want you to open your eye.
At this point, I began to think of several reasons why Ruth is in pain and the first thing that came to my mind is the lungs may have been hyperinflated due to the obstructive nature of COPD. Olson (2017) makes it clear that hyperinflated lungs occur when air gets trapped in the lungs and causes them to overinflate. Hyperinflated lungs can be caused by blockages in the air passages or by air sacs that are less elastic which interferes with the expulsion of air from the lungs. Lebowitz (2018) hyperinflated lungs can cause pain to the patient due to pressure on the chest wall. At this point, I turn to Daniel and asked him about the pressure on the chest of the wall and he answered that this can only be diagnosed by chest x-ray. The barrier is that Ruth cannot express herself and we can only know the severity of her pain through her facial expression. Department of Health (2012), outline that nurse-patient relationship leads to a successful caring relationship and teamwork. Also, using a wide range of verbal and non – verbal languages, such as questioning, good eye contact, listening, touch, body language, and paraphrasing is a vital aspect of communication.
I asked Daniel again about osteoporosis which I know is one of the causes of pain for a patient with COPD which occurs as a severe loss of density in the bones. I went to the nurses’ station to check Ruth medical history on the computer to check if she has a fall in the history to be able to know what might be causing this pain before sending her for a bone density scan.
Having given permission from my mentor to stay with Ruth, I was so happy to do this in other to be able to observe and communicate effectively with her in other to ascertain the cause of her pain. I was standing by Ruth’s bedside hoping she will be touching certain area constantly and that might give a clue. I began to check Ruth body to know where the pain is, on getting to Ruth’s neck region while trying to position her head properly on the pillow to access her neck region, on moving Ruth’s head I heard a groaning sound from her. This sound coming from the person that wasn’t talking before gave me an idea of the location of her pain. The neck region is the most common mobile and useful part of the body and pain in the neck are usually musculoskeletal symptom which is not life-threatening but causes pain and stiffness. Neck pain is not associated with any specific disease or disorder but it is label as soft -tissue rheumatism or muscular/mechanical/postural neck pain. In Ruth’s case, the persistent pain may be caused by inadequately addressed poor compensatory posture , which in turn result in abnormal forces and strain on musculature that must balance and control.
I went to Daniel and explained to him about pain in Ruth’s neck, knowing the benefit of effective communication in health care profession. Also, because this will enables everyone that is involved in Ruth’s care to know what she wants and she will feel respected, especially when she is still at the hospital. According to Department of Health (2013), a key aspect of my role as a student nurse is realising the limitations of what to say and not to say and referring the patient to the appropriate department. Francis Report (2013) highlights that poor communication and staff manners are one of the top protests in the NHS.
Pain is a very important component, and occasionally is the only element for pain processes. Pain is being perceived in the brain (central nervous system) and according to Brooker and Nicol (2011), pain management and subsequent nursing interventions entail a moral, humanitarian, ethical and legal obligation to ensure that people in our care have their pain relieved. Parsons and Preece (2010) said pain management requires competent and knowledgeable practitioners who are fit for purpose.
There is a different strategy for working with a patient in pain and according to Kockrow (2006), we must establish a relationship by listening, showing respect and allowing the patient to choose treatment options. In quest of Ruth’s pain management, we try to understand cultural background and personal behavior of Ruth to be more accurate in assessing Ruth’s pain. To know the type of medication and therapy to give to Ruth, different types of pain intensity scales was been consider.
According to Parsons and Preece (2010), there are some principles to consider in managing a particular pain and failure to consider the true nature of pain that Ruth is experiencing can cause false assumption to be made. The effectiveness of the management depends on a deep understanding of nature of the pain. There are information needed by a nurse to know regarding the cause of Ruth’s pain and major influences on the perception of the pain (Davies and Taylor,2003).
The use of pain assessment tools is mostly recommended by (Kaiser,1992) which emphasize on an effective tool for pain assessment as part of documentation which promotes communication between service user, nurses and medical professionals. Even if we had 0-4 numeric pain assessment scale, this cannot still be used for Ruth because of her syndrome. Rycroft-Malone (2012) explained dementia as a process whereby there is a gradual death of brain cells resulting in loss of brain ability that is severe enough to interfere with normal activities of living. Using the numeric pain assessment will be an inappropriate tool for Ruth as she is unable to verbalise or communicate her pain. Moreover, today’s guidelines powerfully suggest that the use of a homogeneous behavioural pain assessment to nurses who care for uncommunicative service user still needed to fully understand the behavioural and physiological responses of critically ill patients who are experiencing pain (Herr K et al 2008).
Abbey pain scale is being considered for assessing Ruth’s pain, Abbey pain scale is for measurement of pain in people with dementia who cannot verbalise. It is used to assess the followings vocalisation, facial expression, change in body language, behavioural change, physiological change and physical changes. Putting all this scale of preference together we are able to detect that Ruth is experiencing acute pain in the neck.
My mentor, Daniel, said that neck pain can be treated nonsurgical and John (2016) said applying ice can work as an anti-inflammatory to reduce swelling and pain. Initially, it’s better to apply ice or cold packs for neck pain because they can temporarily close small blood vessels and prevent swelling from becoming worse. After a couple of days, ice or heat can be applied on an alternating basis because applying continuous heat can cause increased swelling. On getting to Ruth, I introduce myself with the aim of continuing our good rapport and to seek consent from her even if she is not talking. Royal College of Nursing(RCN) informed that consent is an on-going agreement by a person to receive treatment, undertake procedures or partake in research, after risks, benefits, and alternatives have been adequately explained to them (RCN, 2005). Department of Health (2012) and the 6c’s of nursing highlight on individual and organisation pledge which is important in improving the experience of the patient while at the hospital.
Paracetamol is an antipyretic and analgesic drug has no anti-inflammatory actions. This is known to act through the central nervous system and has a consequence on COX pathways, stimulates descending inhibitory pathways via serotonin and inhibits substance P. Paracetamol is usually prescribed either alone or in combination to all patients who have no contraindications and have post-operative pain.

Feeling
I felt helpless as I could not fully understand why she was upset, and I was unable to reassure or calm her down. I also felt sad and concerned for Ruth condition because she is obviously distressed by the circumstances. I was also concerned about Ruth because of her condition of not been able to communicate effectively about her pain.
When I first saw her the first feeling was that she could be in severe pain and the need to administer some analgesics. Pain is a critical issue because it has the capacity to dehumanize the human person. Lisson (1987) explained pain has an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. From the two definitions, I was able to understand that pain is an individual experience that measuring pain objectively is difficult. Pain can be divided into acute and chronic pain based on the duration. Shipton (1999) differentiate acute pain as a short or limited duration usually associated with traumatic tissue injuries, whereas chronic pain is a discomfort persisting for about 3 to 6 months and may persist beyond the healing period.
Most people are familiar with the pain and awkwardness of a stiff neck, whether it appeared upon waking up in the morning or perhaps developed later in the day after some strenuous activity, such as moving furniture. In most cases, pain and stiffness go away naturally within a week. However, according to Richard (2017) how an individual manages and cares for the stiff neck signs can affect pain levels, recovery time and the likelihood of whether it will return. Symptoms of neck pain can vary widely, at times neck pain may just be a mild nuisance or it could be so excruciating that can avoid any excessive a movement. Most of the time neck pain is in one spot and goes away on its own within a few days or weeks but in some cases, the pain becomes constant or radiates into other body parts, such as the shoulder and arms (John, 2016).

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EVALUATION
This is my first time encountering a dementia patient with acute pain, I have learned and gain a lot about acute pain management. Having built a good patient-nurse relationship (Holland et al 2008), I was so involved in Ruth’s management and I also partake in monitoring Ruth vital signs and recording them accurately. I learned according to Ruth medical history state that she was admitted to the hospital due to dehydration. I asked my mentor series of question and he told me that caring for patients with dementia do not only deal with physical need but they also need psychological support and nurses should know patients react differently to illness (Hughes 2005).Now, I know the nurse-patient interaction can increase psychological, physical health and lifestyle of a patient (Haugan, 2014). It is the role of the nurse to care for their patients and maintain their safety (NMC Code, 2015). When I was talking with the ward sister she explains to me some important factors to look out for when dealing with dementia patient, symptoms and vital signs such as pain, nausea, vomiting, dehydration, and fluid. Anderson (2003) said patient vital signs need to be monitor closely for nurses to be able to respond quickly and appropriately to any changes.
Furthermore, after reassessing Ruth, Daniel went to inform the doctor about her condition and she was prescribed 1g of paracetamol for every 4hour to manage her pain and an ice pack for her neck. I grind the paracetamol in the pot and put it in the cup, mix it with thickener and water for Ruth to be able to swallow because she is having difficulty in swallowing due to COPD.
Analysis
Ruth has always been in a good spirit ever since she was admitted to the ward until the eventful day. The whole process from when Ruth was seen in the morning with pain facial expression till the time I handed her over to the night shift staff has been eventful and educating at the same time. Paracetamol was administered to Ruth as a drug of choice in managing her neck stiffness pain.
Under the supervision of my mentor, I participated wholeheartedly in monitoring Ruth’s vital signs. In addition to monitoring Ruth temperature, I was involved in monitoring Ruth eating and drinking. Also, her fluid balance was being monitored every 1 hour as my mentor explained to me the importance of maintaining fluid balance.
This reflective essay has increased my knowledge and understanding and as well boosted my confidence in the area of pain management. I feel that I have gained knowledge and insight into an important patient assessment. I also have a better understanding of compassionate care in nursing. Francis Report (2013) and NHS Constitution (Department of Health, 2013) also explains that patients care come first and must be able to receive total care from caring, committed and a compassionate staff.

Conclusion
I feel fully involved in the whole process of Ruth pain management. Being my first placement at the rehabilitation ward, I was asking my mentor and every other care professional questions from the moment I saw Ruth and relaying her concern to my mentor. The Ruth’s scenario made me to understand better the importance of patient care in relating to pain management and how to apply different pain assessment tool in assessing the patient in pain.
All health care professional must be skillful when it comes to pain management, pain management in health care should be mandatory and not optional for patient’s safety. Pain management requires professionalism and respect because individuals respond to pain differently. It is very important that staff are up to date with their training on pain management. All healthcare workers should regularly refer to relevant legislation and skills to develop good communication skills in order to maintain and promote care.
Action plan
My action plan and recommendations are to promote the use of the pain assessment tool by educating the nurses and emphasising the importance of this assessment to improve patient outcome. The need for education to train staff on how to use the pain management tools would take both time and money. The NHS is already under extreme financial pressures and money for training is not readily available, however, if an improvement in pain management was successful then patient stay in the hospital may be shorter and can also improve quality of care. I am also aware of the importance of not relying solely on the assessment tools but the use of both good nursing assessment and assessment tools to improve optimal patient care, shortening the recovery time and reducing the likely hood of complication (Ashley and Given 2003). A sedated ventilated, non-communicative patient is vulnerable and relies completely on those providing care for them but as to their family at this anxieties period, education and training will improve patient care and ultimately patient safety which is paramount. Therefore, I will take the knowledge and information I have acquired back to my clinical area as I have a duty to provide a high standard of practice and care always (NMC, 2008).
Peer assessment
At the beginning of the module one of the comment from my peers was that during the TBL session I was not communicating with them. Due to this I made it a point of duty to prepared myself properly by outline my point and do a thorough research on the topics or issued to be discussed before the next TBL session. I utilised textbooks, library and online reading for preparation. I made it a habit to discussed with my peers regarding any issues pertaining to our courses and we also have informal peer review session. All the above has really helped my communication and helped me to participate fully in subsequent TBL and FTW session. The ripples effect of this is seen in other areas of my academics, my communication with others and it has also build my confidence.

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